Children and Adolescents with ADHD

Transcription

1 Children and Adolescents with ADHD Long-term randomized controlled study Dr.Nezla S. Duric Child and Adolescent Psychiatrist/PhD

2 Children and Adolescents with ADHD 3 steps qeeg NEUROFEEDBACK ADHD

3 ADHD Deficit of Self-Regulation ADHD- problems being secondary to inhibited impulse control and lack of self-regulation Leads to a lack of development of other specific and important psychological processes Also includes emotional dysregulation (Barkley) ADHD patients do not lack knowledge or specific skills, but the ability to coordinate / use these appropriately

4 ADHD Etiology "The cause has been attributed to biofactors. The outcome has to do with how the child meets the environment and how the environment meets the child" Professor Eric Taylor at the Institute of Psychiatry, Kings College in London

5 Characteristics of ADHD Lifelong Perspective Behaviour problems Social skills Self esteem Psychiatric comorbidity School performance Smoking/abuse Risk behaviour Social skills Self esteem Psychiatric comorbidity Academic performance Occupational status Psychiatric comorbidity Smoking/abuse Criminality Risk behaviour Social skills Self esteem Pre-school Adolescent Adult School-age College-age Behaviour problems Learning difficulties Social skills Self esteem Academic performance Relationships Social skills Self esteem Halmøy et al, Journal of Attention Disorders, 2009

6 ADHD patho-physiology Cortical maturation Cortical rhytme Arousal level

7 Cortical maturation and EEG Brain activity: Delta(0,1-4 Hz) Theta(4-7 Hz) Alpha(8-11 Hz) Beta(12-30 Hz) Gamma(over 30 Hz)

8 EEG -ADHD Increased levels of Theta and / or reduced levels of Beta or Alpha brain activity in persons with ADHD (Snyder, 2006); elevated Theta/beta ratio in resting EEG (Barry 2003);reduced CNV (Banaschewski,2007) Brain activity: Delta(0,1-4 Hz) Theta(4-7 Hz) Alpha(8-11 Hz) Beta(12-30 Hz) Gamma(over 30 Hz)

9 The international System of electrode/sensor positions (Neuroscience for Kids, Erich H. Chudler)

10 Self-Regulation Arousal Curve Performance Optimum Selfregulationprocesses Arousal

11 ADHD and Treatment Nonpharmacological Treatment Pharmacological Treatment Behavioural Treatments Alternative Treatments Psychostimulants Nonpsychostimulants Neurofeedback

12 ADHD and Treatment Nonpharmacological Treatment Pharmacological Treatment Behavioural Treatments Alternative Treatments Psychostimulants Nonpsychostimulants Neurofeedback

13 ADHD and Treatment - Alternatives Nonpharmacological Treatment Pharmacological Treatment Behavioural Treatments Alternative Treatments Psychostimulants Nonpsychostimulants Neurofeedback

14 Neurofeedback Training of self-regulation of brain activity Application: neurophysiological dysfunction and enhacement of selfregulation ability Feedback: visual, auditory, tactile Heinrich, H., H. Gevensleben, and U. Strehl, Annotation: neurofeedback - train your brain to train behaviour. J Child Psychol Psychiatry, 2007.

15 ADHD and NF games The Juggler

16 Children and Adolescents with ADHD UNIQUE STUDY DESIGN CLINICAL STUDY LARGE SAMPLE SIZE RANDOMIZATION CONTROL GROUP THREE ARMED GROUPS LONG-TERM STUDY

17 Aims of the Study Part I Characteristics ADHD of ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary health care s Explore ability to primary identify healthcare ADHD symptoms. ability Describe to identify children ADHD symptoms. and adolescents with ADHD regarding clinical characteristics. Part II ADHD and Treatment Evaluate the effect of NF treatment on ADHD core symptoms using self-report, parent`s, and teacher`s reports. Compare NF treatment for ADHD children and adolescents with standard medical treatment and combined treatment.

18 Aims of the Study Part I Characteristics ADHD of ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary health care s Explore ability to primary identify health ADHD care s symptoms. Describe ability to children identify ADHD and adolescents symptoms. with ADHD regarding clinical characteristics. Part II ADHD and Treatment Evaluate the effect of NF treatment on ADHD core symptoms using self-report, parent`s, and teacher`s reports. Compare NF treatment for ADHD children and adolescents with standard medical treatment and multimodal treatment.

19 Aims of the Study Part III I qeegadhd in ADHD Describe Define qeeg characteristics changes-biomarkers of Norwegian children and Define adolescents qeegreferred changes_ for Treatment ADHD predictors symptoms. Explore primary health care s Exploare ability to correlation identify ADHD between symptoms. behavioral Describe and children qeegand parametars adolescents with ADHD regarding clinical characteristics.

20 Participants Part I: Characteristics of ADHD Population Referred n = 494 PHC* Other Diagnosis Referred n = 397 (62 %) ADHD Referred n = 187 (38 %) CAMHC** non ADHD n = 91 ADHD n = 96 (51 %) * Primary Health Care ** Child Adolescents Mental Health Clinic, The Fonna Health Trust, Haugesund

21 Participants Part II/III: Treatment and qeeg ADHD Invited Participants: 243 (of 285) Refused Participation: 113 (46 %) T 1 Randomized: 130 (54 %) Medication 44 (34 %) Neurofeedback + Medication 44 (34 %) Neurofeedback 42 (32 %) Dropout: 39 (30 %) T 2 Completed Follow up: 91 (70 %) Medication 31 (24 %) Neurofeedback + Medication 30 (23 %) Neurofeedback 30 (23 %)

22 Methods Part I ADHD ADHD multimodal clinical assessment Anamnesis Clinical examination (blood, EEG, EKG) Psychiatric observation ICD-10 interview Cognitive evaluation Treatment Part II+III Neurofeedback Treatment Pharmacological Treatment Parentreport: Barkley Parent Scale Teacher report: Barkley Teacher Scale Self-report: SRQ qeeg

23 ADHD Treatment in the study Neurofeedback Lubar Theta/Beta SMR protocol 30 sessions: weeks Stimulant Medication Multimodal treatment

24 Time perspective Baseline Treatment Follow-up T 0 T 1 T 2 T 3 Follow-up 24

25 Results Part I: Characteristics of ADHD referred population (N=187) Job active father Job active mother ADHD No ADHD Two or more siblings SPS support CW support Aberrancy in parents relations Father educ. (<=9 years) Mother educ. (<=9 years) Foster family Institution Inadequate parents attendance 5. referred child has ADHD Half of ADHD children live with both biological parents Twice ADHD children in forster family 5. ADHD children in institution Aberrancy in family relations red: p< Percent

26 Results Part I: Characteristics of ADHD referred population (N=187) Average referral age 10,5 år; 82% boys Job active father Job active mother ADHD No ADHD Two or more siblings SPS support CW support rrancy in parents relations Father educ. (<=9 years) Mother educ. (<=9 years) Foster family Institution equate parents attendance berrancy in family relations red: p<0.05 Percent 5. referred child has ADHD Half of ADHD children live with both biological parents Twice ADHD children in forster family 5. ADHD children in institution

27 Results Part I: Characteristics of ADHD referred population (N=187) Clinical examination: Increased risk of low birth weight increased TSH Somatic co-morbid conditions

28 Characteristics of ADHD population ADHD Combined 74% ADHD Hyperactive- Impulsive 22% ADHD Inattentive 4% 4%

29 Characteristics of ADHD population ADHD/nonADHD Sex LowIQ «Social Dysfunctioning»

30 Primary Health Care Primary health care services'sability to identify ADHD symptoms 1/3 of all referred children were referred for ADHD 1/2 of ADHD referred children were diagnozed with ADHD 1/5 ofadhd referred children werenot diagnozed at all

31 Participants Part I: Characteristics of ADHD Population Referred n = 494 PHC* ADHD Referred n = 187 (38 %) CAMHC** ADHD n = 96 (51 %) Other Diagnosis Referred n = 397 (62 %) no ADHD n = 91 none ADHD 34 none diagnose * Primary Health Care ** Child Adolescents Mental Health Clinic, The Fonna Health Trust, Haugesund

32 Primary Health Care The sensitivity was 51% (96/187) regarding primary health care`s ability to recognize ADHD. The specificity was 100% (0/494) Need for specific screening programs and diagnostic guidelines for primary health care

33 Results Part II: Treatment Response based on reports one week later Pre-post Change (within the groups) Treatment Effect (between the groups) Attention Hyperactivity Total score Attention Hyperactivity Total score Parents p < 0,001 p < 0,001 p < 0,001 p = 0,098 p = 0,101 p = 0,173 Teachers p < 0,001 p = 0,209 p < 0,001 p < 0,001 p = 0,425 p = 0,656 Children/ Adolescents p < 0,001 p < 0,001 p = 0,322 p = 0,009 * Adjusted models did not show any effect (power)

34 Results Part II: Correlation Children, Parent`s and Teacher`s reports

35 22 Results Part II: Treatment Response based on reports LONG TERM Effectiveness Patterns towards Treatment Attention 16 Hyperactivity 34 Total score Barkley- teacher Medication Neurofeedback Neurofeedback + Medication Follow up after treatment Attention 22 Hyperactivity 40 Total score Barkley- parents Attention 9 Hyperactivity 10 School performance Self report - child time (months) time (months) time (months)

36 Results Part II: Treatment Response based on reports LONG TERM New evidence for the long-term efficacy of multimodal treatment: stimulant medication NF

37 Conclusion: Part I Referral Environment of ADHD children High ADHD referral in late school age Low diagnostic identification => ADHD-guidelines for Primary Health Care needed Single parent / foster families Low parents education Child welfare Social dysfunction Low IQ High co-morbitity

38 Conclusion: Part I Referral Environment of ADHD children High ADHD referral in late school age Low diagnostic identification => ADHD-guidelines for Primary Health Care needed Single parent / foster families Low parents education Child welfare Social dysfunction Low IQ High co-morbitity

39 Conclusion: Part II Pre-post changes Treatment effect Significant improvement of ADHD coresymptoms regadless treatment type Different focus from raters Neurofeedbackis promising reported shortly after treatment Combined treatment makes no superior efficacy

40 Conclusion: Part II Pre-post changes Treatment effect Significantimprovement of ADHD core symptoms regadless treatment type Different focus from raters Neurofeedbackis promising reported shortly after treatment Multimodal treatment makes superior efficacy in long-term follow up

41 Part III Qeeg Biomarkers Frequences Ratio Predictors The brain's electrical profile under different tasks

42 Future perspectives Follow up over time qeeg analyses

43 Papers 1.Duric N.S., Elgen I. Characteristics of Norwegian children suffering from ADHD symptoms: ADHD and primary health care. Psychiatry Research. 2011, 188 (2011) (Number of citations: 4) 2.Duric N.S., ElgenI. Norwegian Children and Adolescents with ADHD A Retrospective Clinical Study: Subtypes and ComorbidConditions and Aspects of Cognitive Performance and Social Skills. Adolescent Psychiatry, 2011, Vol. 1, No. 4. (Number of citations: 3) 3. Duric N.S., Assmuss J., Gundersen D., Elgen I. Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports. BMC Psychiatry, 2012, Vol.12, No. 1; 107. (Number of citations: 12) 4. Duric N.S., Assmuss J.,Elgen I. NF treatment of children and adolescents with ADHD: Self-reported evaluation. Child and Adolescent Psychiatry and Mental Health, December 2013.

44 I have ADSL, What s difference with ADHD? It goes faster with ADHD

45 Thank you